Therapy Technologies PDF

Sensory-Motor Systems Lab Institute of Robotics and Intelligent Systems Balgrist University Hospital Rehabilitation & Inclusion: Therapy Technologies Prof. Dr. Dr. h.c. Robert Riener ...

Sensory-Motor Systems Lab Institute of Robotics and Intelligent Systems Balgrist University Hospital Rehabilitation & Inclusion: Therapy Technologies Prof. Dr. Dr. h.c. Robert Riener  Rehabilitation Lecture Topics Acute phase, medicine Early rehab Diagnosis, Prevention Pre-rehab Subacute phase, Therapy Cost models Society Therapy technologies Secondary Environment Data prevention Barrier- Home & free living Technology Medicine remote Legislation Economy therapy Inclusion at work Organisation Inclusion, Assistive Social inclusion Monitoring Chronic phase, technologies Training Long-term phase, Parasports Assistance Device Certification 4 Overview of Today’s Lecture Lower limb therapy devices Upper limb therapy devices Virtual Reality (VR) technologies Intensive care devices Robot-aided care Electrical Stimulation 5  16 Mill per year worldwide Stroke Robotics in Rehabilitation Stroke Incidences USA: ~ 800’000 new cases per year Europe: ~ 1.1 million new cases per year China: ~ 2-3 million new cases per year Trend: Age-related increase BDH Klinik Elzach 7 Stroke Secondary complications Muscle atrophy Cardiopulmonary problems Pressure sores (decubitus) Osteoporosis Incontinence Manual Treadmill Training (in the 90s) Harness Counterweight Treadmill Disadvantages of Manual Training For the therapist Physically exhausting Ergonomically inconvenient For the patient Limited in time Gait pattern not optimal For the health care system Needs personnel and time Cost intensive More than 90% of the time not active Activity of Children Infants and young children train a lot Before running (< 12 months): 7’000 – 26’000 leg movements per day Toddler (12-19 months): ~14’000 steps per day Upper extremities (12 months): ~2’400 reach & grasp actions per day Lower Limb Therapy Devices Motivation of Robot-Aided Therapy Advantages of Robotic Training Assistance for therapists Longer training durations for patients More complex movements, e.g. stair climbing, upper limb movements Highly repetitive and comparable Measureable, quantitative assessment Increased motivation, e.g., via gamification Safe environment Lokomat, Hocoma AG Balgrist University Hospital Exoskeleton: Lokomat Lokomat, Colombo & Dietz, Zurich, 90s Lokomat®  Lopes I: Based on Cable-Driven SEA* Actuation *SEA: Serial-Elastic Actuation H. Van der Kooij et al., University of Twente, NL Endeffector-Based: GaitTrainer GaitTrainer von Reha-Stim, Berlin Endeffector-Based: G-EO RehaTechnology Lokohelp, Woodway  Body-Weight Support Systems Static Counterweights Elastic Springs Actuated force sensor controller C elastic spring winch counterweight actuator What are advantages and disadvantages? Actuated System Lokolift Force sensor Force control Desired force winch Bioness Vector, ELITE KineAssist Stationary and Mobile Versions Andago, Hocoma Exoskeletons for Gait Therapy EksoBionics Cyberdyne Rewalk Honda 31 Stiff Exoskeletons versus Soft Exosuits Advantages/ Disadvantages? Rewalk Robotics, 2016 Conor Walsh et al., 2016  Garment layer Tendon driver unit Ligament hip Knee moment arm Ligament knee Power layer MyoSuit Experience till February 2022 17 Different Pathologies, including Spinal cord injury (incomplete tetra/paraplegia) Muscle dystrophies (FSHD, Bethlem, Becker, etc.) Multiple Sclerosis Parkinson’s Disease Plegias after stroke & traumatic brain injuries Orthopedic impairments Cardiac patients (heart insufficiency) Pediatric patients (CP, SCI, TBI) 62 trials involving 2440 participants. People receiving electromechanical‐assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people … without these devices. … people in the first 3 months after stroke and those who are not able to walk seem to benefit most … role of the type of device is still not clear. 2020 Upper Limb Therapy Devices Challenges of Therapy of Upper Extremities compared to Lower Extremities? Complex Shoulder Anatomy Complex Shoulder Anatomy Acromio- clavicular joint Clavicle Sterno- Scapula Clavicular Gleno- joint humeral Scapula- joint Thoracic joint Humerus Sternum Thorax Veeger, J. Biomechanics, 2007 Drakeet al., Gray’s Anatomy, 2009  Complex Shoulder Anatomy Patient Healthy sternum spine spine Versatility of Arm and Hand Functions Finger push Flat-hand Pinch/key Span grip push grip Disk/precision grip Hook grip Power/cylinder grip Mechanical Structures Endeffectors Exoskeletons Exosuits MIT-Manus, since 90s https://www.youtube.com/watch?v=EN5_24biEWU Bi-Manu-Track (Hesse Arm Trainer), ca. 2003 Stefan Hesse et al., 2003 Weight Support Systems https://www.youtube.com/watch?v=cJ_YIVQk90c Swedish Help Arm ArmeoBoom, Hocoma Diego, Tyromotion ArmeoSpring, since ca. 2008 ARMin: The 1st Exoskeleton, since about 2005 ArmeoPower, ca. 2010 Exoskeletons with Pneumatic Actuation, ca. 2009 Pneu-WREX and BONES Exoskeletons – UC Irvine Connect the Patients Collaborative Training Player BLUE ETH Zurich Player RED Uniklinik Balgrist Social Interaction through ARMin Collaborative Training The Myoshirt, ca. 2020 Shoulder Muscular Instability weakness Stability Mobility Scapular Orthosis BOA pressure mechanism Statically constrained Improves Shoulder Stability and Range of Motion Female patient with FSHD muscular dystrophy Exosuits: Arm and Hand Assistance, since 2015 Connor Walsh Lorenzo Masia Harvard, Boston NTU, Singapur Kyujin Cho SNU, Seoul 45 trials involving 1619 participants: Robot-assisted arm training improved activities of daily living scores, arm function, and arm muscle strength. Quality of the evidence is high. 2018 Exoskeletons vs. Endeffectors Two Different Mechanical Interaction Concepts Endeffector- Exoskeleton based Main Challenge with Exoskeletons Alignment of robotic with anatomical joint axes Human Robot Main Challenge with Exoskeletons Alignment of robotic with anatomical joint axes Human Human Robot Robot Main Challenge with Endeffector-Based Robots Control of Posture and Movements Human Human Robot Robot Are Exos better? Are Exoskeletons Better? Endeffector-based systems: Easier to apply Exoskeletons: Allow more complex movements with larger ROMs & can be made mobile Virtual Reality (VR) Technologies Lokomat® and Virtual Reality Pediatric Gait Therapy and Virtual Reality Collaboration: ETH Zurich Children Hospital Affoltern a.A., Hocoma, ZHDK ARMin and Virtual Reality ARMin and Virtual Reality Objectives of Virtual Reality Provide a Practical Training Setting Enable training of quasi-realistic tasks, e.g., ADL tasks Individual and gradual difficulty adjustments to patient Intuitive instructions by context Improved Feedback and Assessment Inform patient about his/her efforts (bars, graphs, colours) Measured scores inform therapist about rehabilitation status Stronger Neurophysiological Effects Increased cognitive stimulation and challenge Increase of motivation by provision of reward (“game instinct”) Lokomat® and Virtual Reality  Multimodal Input and Output Input: Output: Biomechanical & Psychophysiological Stimuli Recordings Body weight support Skin fResp temp. Sound Graphics HR & HRV (Task) Guidance or Skin resistance friction force Treadmill speed Force, position & speed Pleasant Scenario Arousing Scenario VR-Supported Rehab: CAREN, Motek Key features Interactive and dynamic VR games for rehabilitation of gait and full-body movement disorders Multi-sensory recordings for advanced rehabilitation protocols Advanced software offers custom- adapted research and clinical applications VR-Supported Psychotherapy Therapies against Phobias Acrophobia: fear of height => e.g., virtual elevator Aviophobia: fear of flying => e.g., flight simulator Fear of driving => e.g., driving simulator Social phobias => e.g., performance in front of audience Claustrophobia: Fear of small spaces => e.g., virtual narrow rooms Agoraphobia: Fear of large spaces => e.g., different outdoor simulation spaces Arachnophobia: Fear of spiders => e.g., spider treatment simulator VR Treatment of Fear of Flight, since 90s Wiederhold Mühlberger VR Pain Therapy, since 90s Intensive Care Devices Powered Tilt Table Erigo® Early Training of Inclination and Mobilisation Erigo®Pro, Hocoma Early and safe mobilization of severely impaired patients even in acute care Progressive verticalization up to 90° Cyclic leg movements 8-80 steps/min Cyclic leg loading (up to 50 kg) allows enhanced cardiovascular output Improves orthostatic tolerance through Functional Electrical Stimulation (FES) Sensorimotor stimulation improves patient awareness Erigo®Pro, Hocoma (at CHUV, Lausanne) Cardiovascular Stabilisation with Erigo® Heart rate Reference Systolic blood pressure Controller Diastolic blood pressure Functional electrical stimulation Stepping frequency Inclination angle Control of Heart Rate 50% 62.5bpm 0% 53bpm Desired HR 61.7bpm 52.8bpm Measured HR Desired HR Measured Averaged HR HR [bpm] 1 Norm. Height 0.5 0 time [s] Control of Diastolic Blood Pressure 0% 100% 50% 0% dBP [mmHg] desired dBP norm. height time [s] Early Mobilisation with VEMO  Innovative und leitliniengerechte Frühmobilisation 500+ 5000+ PATIENTEN THERAPIEN Aufrecht gehen, direkt im Bett! REFERENZ KLINIKEN Schön Klinik Bad Aibling Harthausen: Neurologische und anästhesiologische Intensivmedizin BG Unfallklinik Murnau: Zentrum für Rückenmarkverletzte, Intensivmedizin Charité Universitätsmedizin Berlin: Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin LMU Klinikum München Großhadern: Neurologische und internistische ICU mit Schwerpunkt auf Organtransplantationen Landeskrankenhaus Hochzirl-Natters, Tirol: Abteilung für Neurologie (Schlaganfall, MS, Querschnitt, SHT) Bavaria Klinik Bad Kissingen: Neurologische (Früh-) Rehabilitation (Phase B) Universitäts- und Rehabilitationskliniken Ulm Neurologische (Früh-) Rehabilitation (Phase B) Therapiezentrum Burgau Neurologische Fachklinik, (Früh-) Rehabilitation (Phase B) ZUM VIDEO PROPRIETARYwww.reactive-robotics.com AND CONFIDENTIAL www.reactive-robotics.com Decubitus Prevention Intensive Care Bed «SLK IV» 20 modular air chambers Intelligent pressure management via sensors and control → Avoid large pressure peaks Decubitus Prevention INSYDE, FHG (IIS), with sensors and actuators for shape adaptation Decubitus Prevention Intensive Care Bed “multicare” Decubitus Prevention & Mobility Support Intensive Care Bed “TotalCare SpO2RT” Large range of inclination to support transfers Integrated weighting system Automatic postural changes Decubitus Prevention & Mobility Support Resyone, Panasonic 104 Somnomat: Closed-Loop Rocking Bed for Treatment of Patients Mechanical Sensing Intervention Processing Slide 105 Till, 10 Years Old Boy Suffers from Mitochondrial Disorder Paralysed and does not sleep at night Results of 6 Month Study Sleep Duration Fatigue Caregiving Effort 4 Mean Interaction Score (Interactions / Hour) 3 2 1 0 en t en t t ve ut nt ash n n d Wa tion n d Wa tion ve ed rv u rv u rv u o tio io te sho te sho te sho er o nt om na W nti nt n e a t i st W er 1s ccu in in in A lI h ng 4t 3r 2n Fi ti et G Below threshold - 75% caregiving interaction + 60 min (p=0.005**) of severe fatigue - 40% overall caregiving time Patient: 12 year old boy with primary mitochondrial disease [Breuss et al., 2024 - doi: 10.1111/jsr.1415 Robot-Aided Care “Robotic Nurses” Applications Patient lifting, turning, transfer Delivery Services Post-operative care Decubitus prevention Wellbeing and wellness Who wants to receive care from a robot instead of a human? Who prefers to get lifted by a mechatronic device? Who prefers a robot to perform intimate body hygienic tasks?  Robots for Care: Survey by the Körber Stiftung «Ich würde mich unwohl fühlen, wenn Would ich bei Krankheit oderyou prefer a machine or a im Alter durch einen human Roboter betreut for intimate body hygiene? würde» => Different answers expected Terminator 1984-2009 Patient Lifting and Transfers Humanoid Robot RI-MAN (Japan) Weight 100 kg, size 158 cm Load capacity only 18 kg Facial recognition, hearing and olfactory functions (8 odors) for localization Riken, Japan Patient Lifting and Transfers Humanoid Robot RIBA II Load capacity 80kg Compliant joints Silent motors Omnidirectional plattform Soft skin (plastic foam) Touch sensors Face and speech detection Recognizes hospital personnel, reacts to environment Weight of device: ~225kg Riken, Japan & Tokai Rubber Industries (TRI) Patient Lifting and Transfers Waverley Glen, Lifting Systems Patient Lifting and Transfers Waverley Glen, Lifting Systems Patient Lifting and Transfers Sure-Lift Lifting Devices Easy/Sure-Lift Electrical or hydraulic lifting Easy-Lift actuation For tasks with high force support Increased safety Simple, portable, home use Patient can feel anxious Sit-to-Stand Transfer Aids Jutta Ehinger, Dipl. Pflegewirtin Robots for Communication Pepper, Softbank Robots to Improve Well-Being and Communication Psychotherapy with Robotic Seal “Paro” Five kinds of sensors: to detect tactile, light, audition, temperature and posture Takanori Shibata, AIST, Tsukuba, Japan Robots to Improve Well-Being and Communication Robotics Pets Hasbro Delivery Services Delivery of Medication Sorts pharmaceutic medications for individual patients Delivers medication to the patients in hospital rooms Staff takes medications and provides it to patients Panasonic, Japan Delivery Services TUG Roboter, AETHON Electrical Stimulation FES Motor Neuroprosthetics Yesterday W. Liberson 1961 L. Galvani, 1791 FES Stimulator I pw A t T=1/f FES for Training & Therapy RehaMove, Hasomed Brain Stimulation Types of brain stimulation tDCS: transcranial direct current stimulation tACS: transcranial alternating current stimulation tPCS: transcranial pulsed current stimulation tRNS: transcranial random noise stimulation TMS, Wikipedia Source TMS: transcranial magnetic stimulation focus Go Flow Pro, foc.us Thank You! Additional Slides: Further Examples Lokomat® Group Therapy Autoambulator Health South, USA Lopes II https://www.youtube.com/watch?v=TlDUrSUMpgc University of Twente, Netherlands THERA-Trainer, lyra RehaWalk, Zebris V-Gait System, Motek Body-Weight Support System: ZeroG National Rehabilitation Hospital, Washington D.C., USA Slide 149 HAL: Hybrid Assistive Limb Actuated gait orthosis; EMG controlled Tsukuba University, JP HAL: Hybrid Assistive Limb (latest versions) http://ccr-deutschland.de/en/healthcare/ MyoSuit Experience till February 2022 Patient Tests More than 750 patients tested for R&D Till Feb 2022: 3'767’349 steps performed Sold to CH, DE, IT, Benelux 17 Different Pathologies, including Spinal cord injury (incomplete tetra/paraplegia) Muscle dystrophies (FSHD, Bethlem, Becker, etc.) Multiple Sclerosis Parkinson’s Disease Plegias after stroke & traumatic brain injuries Orthopedic impairments Cardiac patients (heart insufficiency) HapticMASTER, Motek, since ca. 2000 https://www.youtube.com/watch?v=RvXGnFky3c4 Pediatric Arm Therapy Robot ChARMin Pediatric Arm Therapy Robot ChARMin Pediatric Arm Therapy Robot ChARMin Exoskeleton Rice Wrist, ca. 2011 With 4 DOF at Forearm & Wrist Rice University https://www.youtube.com/watch?v=lMUSUkDNUGE Exoskeleton HARMONY, ca. 2015 Features 7 DOF per arm: 5 at shoulder, 1 at elbow, 1 at lower arm Serial elastic actuators University of Texas in Austin https://www.youtube.com/watch?v=9EF1hmdt83c  ARMin Becomes AnyExo Accurate Haptic Interaction DYNAMIC Fast & Intensive Movemens ADL Capable => Large ROM VERSATILE Movements Close to Body Intuitive & Adaptive for Patient & Therapist § Exosuit: Rapael Smart Gove NEOFECT, ca. 2020 Passive recording glove Input device to play computer games Exosuit: GLOREHA Hand Rehabilitation, ca. 2020 VR-Supported Rehab: DynSTABLE, Motek Key features Dynamic balance platform for training and assessment Objective outcomes to monitor progression Immersive virtual environments increase patient engagement VR-Supported Rehab: CAREN, Motek Allegro – Bionic Training Companion Somnomat: Closed-Loop Bed for Snoring and Apnea Prevention Mechanical Sensing Intervention Processing Slide 170 Anti-Snoring: Closed-Loop Postural Intervention Z Z Z ZZZ Z ZZ Z Z ZZ Z ZZ Z Snoring Intervention activity Actuated bed Sensing Intervention Measured command Snoring activity Processing & Control Apnea Project: Background Background Definition of Apnea: Drop of airflow of at least 90% for a duration of at least 10 s Obstructive sleep apnea (OSA) highly prevalent in general population (up to 30% in males, increasing with age), Heinzer et al. 2015 In 56% to 76% of the OSA patients, the AHI (apnea hypopnea index) correlates with the sleep position, Ravesloot et al. 2017 Idea: change position for positional obstructive sleep apnea (POSA) patients to reduce AHI Patient Lifting and Transfers Lifting System Liko (D) Horizontal Transport Simple use Weight of device: 13 kg Load capacity: 400 kg Post-Operative Care Communication Assistance Robot Enable comfortable communication between people who are bed ridden or have limited mobility and other people Hospi, Panasonic Delivery Services AGVS Robotnik FES Stimulated Muscles for Gait Thigh Flexion Reflex (lateral view) M. Gluteus M. Quadriceps Hamstrings Flexion Reflex Brain Stimulation magnetic coil electrodes or Stimulator Determines stimulation strength, frequency and length Electrodes or magnetic coil Apply voltage to skin or magnetic field power source stimulator Power source Provides electricity to give stimulation Adapted from IISART Education Material